Reducing financial hardship from healthcare spending in low- and middle-income countries: a rapid evidence assessment
Households across low- and middle-income countries (LMICs) continue to face significant financial hardship as a result of healthcare costs. Out-of-pocket payments can push families into poverty, deepen existing inequalities, and force people to delay or forego care altogether. Understanding which policies and interventions effectively protect households from these financial risks is critical for strengthening health systems and advancing universal health coverage. To tackle this challenge, hera recently completed a rapid evidence assessment (REA) for the UK’s Foreign, Commonwealth and Development Office (FCDO).
A rapid and rigorous synthesis of the evidence
The REA synthesized findings from 214 studies across 40 countries, covering interventions implemented between 1999 and 2024. These interventions ranged from health financing reforms and demand-side approaches to social protection measures and broader social determinants of health. By mapping these interventions against key indicators—such as out-of-pocket expenditures (OOPE), catastrophic health expenditures (CHE), and healthcare-related impoverishment—the team built a comprehensive picture of what works and why.
The REA was designed to provide a policy-relevant, rigorous synthesis of existing research, conducted within a short timeframe and guided by the principles of systematic review. Its purpose was to support FCDO and other stakeholders working to strengthen health systems in LMICs by identifying:
Which policy choices and interventions are most effective in improving financial protection
Which approaches are less effective, or work only under certain conditions
How and why these interventions succeed or fail in different contexts
The findings are intended to directly inform programming, policy design, and advocacy efforts related to health financing and financial protection.
By addressing not only what works but also why and under what conditions, the REA moves beyond simple effectiveness rankings to provide more nuanced, decision-relevant insights.
What did we learn?
Rather than focusing narrowly on traditional health financing reforms, the review developed a broader typology of interventions reflecting the multiple pathways through which households experience financial hardship from healthcare costs. The typology spans four domains:
Health financing and health system interventions
Demand-side approaches that reduce out-of-pocket healthcare costs
Social protection measures that increase household resources available for healthcare
Social determinants of health, which lower health needs and associated costs
Mapping interventions across this typology enabled a more comprehensive and comparative analysis of financial protection strategies. Three key insights emerged:
No single intervention guarantees equity: no specific type of strategy, including those targeting poorer and marginalised groups, consistently delivered stronger financial protection outcomes.
Context is critical: political, economic, and bureaucratic conditions often determine whether policies succeed or fail.
A mix of approaches works best: combining health system reforms with demand-side measures and social protection can substantially reduce household health-related financial strain.
Both the full assessment and the newly published policy brief are now publicly available and can be accessed here:
Rapid evidence review: Improving Healthcare-Related Financial Protection in Low- and Middle- Income Countries
Policy brief: Intervention effects on health-related financial protection in LMICs
Together, these outputs provide one of the most comprehensive syntheses to date on how LMICs can reduce financial hardship from healthcare spending, offering valuable guidance for governments, donors, and partners committed to building more equitable and financially protective health systems. For those working in health policy, this evidence offers actionable insights to design interventions that truly protect households from financial shocks.
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